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Objectives: To assess trends in the ordering of cholesterol tests by general practitioners (GPs), and to assess whether the trend in ordering cholesterol tests is consistent with the recommendations in the Dutch guidelines for GPs.Methods: Analysis of total cholesterol and lipid fraction tests at the Maastricht diagnostic centre, which serves all 85 GPs in the region, over the years 1984–1992. Main outcome measures are the number of cholesterol, HDL, LDL and triglyceride tests per year, and the number of cholesterol tests per GP per year. The frequency of cholesterol and lipid fraction testing in ‘new patients’ (patients presenting for cholesterol testing for the first time) are indicators for adherence to die guidelines on the diagnostic procedure. Data on new patients were available for the years 1989–1992.Results: There was an overall increase in the total number of cholesterol tests of 173% between 1984 and 1992. There is considerable and stable inter-doctor variation. In new patients, 13.5% of male a...

BACKGROUND In a population of 85 general practitioners diagnostic test ordering behaviour has been changed by means of repeated individual feedback provided since 1985. OBJECTIVES We studied practitioner and practice characteristics which may explain differences in test ordering behaviour and in the extent to which general practitioners tend to change their behaviour according to the feedback. METHOD In order to trace such variables, 75 general practitioners were interviewed. In our study request data from individual general practitioners were related to data from several questionnaires. RESULTS We found no practice characteristics which were of influence on the number of test requests by the general practitioner. Explanatory practitioner characteristics for this were found to be years of experience and working hours per week in practice. CONCLUSIONS More years of experience as a general practitioner and a shorter duration of consultations correlated with a better response to advice given in the feedback.

The number of good quality studies on the effect of feedback and reminders on diagnostic and preventive activities in ambulant practice is still low. The interventions and procedures studied differ widely, and the reporting of the results is insufficiently precise. This makes comparison difficult and quantitative pooling impossible. Nevertheless, the literature supports the contention that feedback reduces the use of diagnostic tests and the costs thereby engendered. It also discloses a positive effect of feedback on the adherence of medical practice to guidelines or standards. In this respect, the effect of reminders seems to exceed that of classical methods of feedback. There is still a need for research on the effect of feedback, reminders and other instruments for quality assurance on various aspects of medical performance in different settings.

BackgroundIn our region (Eastern South Limburg, The Netherlands) an open access echocardiography service started in 2002. It was the first service of this kind in The Netherlands. Our study aims were: (1) to evaluate demand for the service, participation, indications, echocardiography outcomes, and management by the general practitioner (GP); (2) to analyse changes in indications and outcomes over the years.Methods(1) Data from GP request forms, echocardiography reports and a retrospective GP questionnaire on management (response rate 83%) of 625 consecutive patients (Dec. 2002 - March 2007) were analysed cross-sectionally. (2) For the analysis of changes over the years, data from GP request forms and echocardiography reports of the first and last 250 patients that visited the service between Dec. 2002 and Feb. 2008 (n = 1001) were compared.ResultsThe echocardiography service was used by 81% of the regional GPs. On average, a GP referred one patient per year to the service. Intended indications for the service were dyspnoea (32%), cardiac murmur (59%), and peripheral oedema (17%). Of the other indications (22%), one-third was for evaluation of suspected left ventricular hypertrophy (LVH). Expected outcomes were left ventricular dysfunction (LVD) (43%, predominantly diastolic) and valve disease (25%). We also found a high proportion of LVH (50%). Only 24% of all echocardiograms showed no relevant disease. The GP followed the cardiologist's advice to refer the patient for further evaluation in 71%. In recent patients, more echocardiography requests were done for 'cardiac murmur' and 'other' indications, but less for 'dyspnoea'. The proportions of patients with LVD, LVH and valve disease decreased and the proportion of patients with no relevant disease increased. The number of advices by the cardiologists increased.ConclusionOverall, GPs used the open access echocardiography service efficiently (i.e. with a high chance of finding relevant pathology), but efficiency decreased slightly over the years. To meet the needs of the GPs, indications might be widened with 'suspicion LVH'. Further specification of the indications for open access echocardiography - by defining a stepwise diagnostic approach including ECG and (NT-pro)BNP - might improve the service.

Background: Abnormal results of diagnostic laboratory tests can be difficult to interpret when disease probability is very low. Although most physicians generally do not use Bayesian calculations to interpret abnormal results, their estimates of pretest disease probability and reasons for ordering diagnostic tests may - in a more implicit manner influence test interpretation and further management. A better understanding of this influence may help to improve test interpretation and management. Therefore, the objective of this study was to examine the influence of physicians’ pretest disease probability estimates, and their reasons for ordering diagnostic tests, on test result interpretation, posttest probability estimates and further management. Methods: Prospective study among 87 primary care physicians in the Netherlands who each ordered laboratory tests for 25 patients. They recorded their reasons for ordering the tests (to exclude or confirm disease or to reassure patients) and their pretest disease probability estimates. Upon receiving the results they recorded how they interpreted the tests, their posttest probability estimates and further management. Logistic regression was used to analyse whether the pretest probability and the reasons for ordering tests influenced the interpretation, the posttest probability estimates and the decisions on further management. Results: The physicians ordered tests for diagnostic purposes for 1253 patients; 742 patients had an abnormal result (64%). Physicians’ pretest probability estimates and their reasons for ordering diagnostic tests influenced test interpretation, posttest probability estimates and further management. Abnormal results of tests ordered for reasons of reassurance were significantly more likely to be interpreted as normal (65.8%) compared to tests ordered to confirm a diagnosis or exclude a disease (27.7% and 50.9%, respectively). The odds for abnormal results to be interpreted as normal were much lower when the physician estimated a high pretest disease probability, compared to a low pretest probability estimate (OR = 0.18, 95% CI = 0.07-0.52, p < 0.001). Conclusions: Interpretation and management of abnormal test results were strongly influenced by physicians’ estimation of pretest disease probability and by the reason for ordering the test. By relating abnormal laboratory results to their pretest expectations, physicians may seek a balance between over- and under-reacting to laboratory test results. Background Laboratory tests are frequently ordered in routine primary care as part of the diagnostic process, even though the physician’s pretest expectation may often be that the probability of disease is low, and they often order tests for other than purely medical reasons, such as patient

OBJECTIVE--To assess the effect of feedback on the test ordering behaviour of general practitioners. DESIGN--Comparison of requests at two diagnostic centres, and internal comparison between tests which were discussed in feedback and tests which were not. SETTING--A diagnostic centre in Maastricht giving feedback and another elsewhere in the Netherlands (laboratory A) not giving feedback. SUBJECTS--All 85 general practitioners in the region of Maastricht, and all general practitioners in the region of laboratory A. MAIN OUTCOME MEASURES--Numbers of tests requested by general practitioners. RESULTS--Requests at the Maastricht diagnostic centre decreased soon after the onset of feedback whereas there was a persistent increase in requests at laboratory A. Tests that were discussed showed the strongest decrease (maximum 40%), though tests that were not discussed decreased as well (maximum 27%). CONCLUSIONS--Feedback on diagnostic requests may exert a strong influence on request behaviour. Four years after the onset of feedback the effects were still noticeable.

Feedback to general practitioners about the diagnostic tests they request reduces the number of requests.1 This effect disappears, however, soon after feedback is stopped.2 Most studies have been short, so data on the long term effects of feedback are lacking.3 The Diagnostic Coordinating Centre Maastricht has provided feedback continuously since 1985, resulting in a more rational use of tests and fewer requests.4 5 We report the effects of nine years of feedback. We also investigated its effects on requests for tests that were not advised but had a recommended alternative. We expected the effects to be greatest for such requests. We thought that if general practitioners had a choice of alternative tests they might be more willing to follow recommendations. The diagnostic coordinating centre coordinates all requests from the 85 general practitioners in the Maastricht region. Written …

STUDY OBJECTIVE--To compare three days9 and seven days9 treatment with co-trimoxazole in women with acute dysuria, strangury, and urinary frequency or urgency. DESIGN--Randomised double blind placebo controlled trial. SETTING--General practices in the south east of The Netherlands. PATIENTS--327 Non-pregnant female patients aged 12 to 65. INTERVENTION--161 Women were allocated to three days9 treatment (co-trimoxazole 960 mg twice a day), and 166 women were allocated to seven days9 treatment (co-trimoxazole 960 mg twice a day). MAIN OUTCOME MEASURE--Resolution of symptoms at one, two, and six weeks. RESULTS--The rates for resolution of symptoms were not significantly different between the two groups. Cumulative rates of recurrence after three days9 and seven days9 treatment were 31/139 (22%) and 23/151 (15%) respectively six weeks after entry (p = 0.16). Adverse effects occurred in a quarter of women given three days9 treatment compared with a third of women receiving seven days9 treatment (p = 0.29). In only two patients did adverse effects necessitate stopping treatment. CONCLUSIONS--Three days of co-trimoxazole seems to be as effective as a seven days9 course for treating acute urinary tract infection in non-pregnant women.

Background It is difficult to keep control over prescribing behaviour in general practices. The purpose of this study was to assess the effects of a dissemination strategy of multidisciplinary guidelines on the volume of drug prescribing. Methods The study included two designs, a quasi-experimental pre/post study with concurrent control group and a random sample of GPs within the intervention group. The intervention area with 53 GPs was compared with a control group of 54 randomly selected GPs in the south and centre of the Netherlands. Additionally, a randomisation was executed in the intervention group to create two arms with 27 GPs who were more intensively involved in the development of the guideline and 26 GPs in the control group. A multidisciplinary committee developed prescription guidelines. Subsequently these guidelines were disseminated to all GPs in the intervention region. Additional effects were studied in the subgroup trial in which GPs were invited to be more intensively involved in the guideline development procedure. The guidelines contained 14 recommendations on antibiotics, asthma/COPD drugs and cholesterol drugs The main outcome measures were prescription data of a three-year period (one year before and 2 years after guideline dissemination) and proportion of change according to recommendations. Results Significant short-term improvements were seen for one recommendation: mupirocin. Long-term changes were found for cholesterol drug prescriptions. No additional changes were seen for the randomised controlled study in the subgroup. GPs did not take up the invitation for involvement. Conclusion Disseminating multidisciplinary guidelines that were developed within a region, has no clear effect on prescribing behaviour even though GPs and specialists were involved more intensively in their development. Apparently, more effort is needed to bring about change.

Background To perform out-of-hours primary care, Dutch general practitioners (GPs) have organised themselves in large-scale GP cooperatives. Roughly, two models of out-of-hours care can be distinguished; GP cooperatives working separate from the hospital emergency department (ED) and GP cooperatives integrated with the hospital ED. Research has shown differences in care utilisation between these two models; a significant shift in the integrated model from utilisation of ED care to primary care. These differences may have implications on costs, however, until now this has not been investigated. This study was performed to provide insight in costs of these two different models of out-of-hours care. Methods Annual reports of two GP cooperatives (one separate from and one integrated with a hospital emergency department) in 2003 were analysed on costs and use of out-of-hours care. Costs were calculated per capita. Comparisons were made between the two cooperatives. In addition, a comparison was made between the costs of the hospital ED of the integrated model before and after the set up of the GP cooperative were analysed. Results Costs per capita of the GP cooperative in the integrated model were slightly higher than in the separate model (ε 11.47 and ε 10.54 respectively). Differences were mainly caused by personnel and other costs, including transportation, interest, cleaning, computers and overhead. Despite a significant reduction in patients utilising ED care as a result of the introduction of the GP cooperative integrated within the ED, the costs of the ED remained the same. Conclusion The study results show that the costs of primary care appear to be more dependent on the size of the population the cooperative covers than on the way the GP cooperative is organised, i.e. separated versus integrated. In addition, despite the substantial reduction of patients, locating the GP cooperative at the same site as the ED was found to have little effect on costs of the ED. Sharing more facilities and personnel between the ED and the GP cooperative may improve cost-efficiency.